Sequence of Complete Health History
1) Biographical data
--Language & authorized representative
--Source of history
2) Reason for seeking care
3) Current health or history of current illness
--PQRST (any symptoms)
--U (understanding)
4)Past health
5) Med recon
6) Family history
7) Review of
Biographical Data
Name
Address and phone number
Age and birth date
Birthplace
Sex
Marital status
Race
Ethnic origin
Occupation�usual and present
Source of information
Language &authorized representative
Sources of History
-Record who gives the information (pt, caregiver)
-Judge how reliable the informant seems to communicate
-Note if the person is ill
Reason for Seeking Care
a brief, spontaneous statement in the person's own words describing the reason for the visit
1 or 2 signs/symptoms and duration
Sypmtom - subjective (ear hurting)
Sign - objective (101 fever)
-CHRONOLOGICAL RECORD
8 Critical Characteristics of Symptoms/Complaint
Current Health/History of Current Illness
-Location - Head pain
-Character or Quality
-Quantity/Severity
-Timing
-Setting
-Aggravating/Relieving Factors
-Associated Perception
-Patient's perception
PQRSTU
PQRST mnemonic
P: Provocative or palliative
Q: Quality or quantity
R: Region or radiation
S: Severity scale
T: Timing
U: Understand patient's perception
Location
specific area
Character/Quality
specific descriptive terms (burning, sharp, dull, aching, throbbing)
"Does vomit look like coffee grounds?
Quantity
Quantify sign or symptom
"Profuse menstrual flow soaking five pads per hour
Timing
When did the symptom first appear
"The pain started yesterday
Setting
where it first happened
Aggravating/Relieving Factors
what makes the pain worse or what helps
Associated Factors
Is the primary symptom associated with others.
"Side effects of medicine
Patient's perception
What do you think is wrong.
"How has this affected you
Past Health
-Childhood illness
-Accidents/Injuries
-Serious or Chronic Illness
-Hospitalizations
-Operations
-Immunizations
-Obstetrics (pregnancy)
---Gravida, Para, Pre-term, AB, Living
-Last Examination date
-Allergies
-Current medications
Gravida
number of pregnancies
term
number of deliveries in which the fetus reached full term
preterm
number of preterm pregnancies
living
number of living children
ab
abortions
Immunizations
up to date? recommend vaccines
Last exam
note date
Allergies
To what and what is the reaction
Medication Reconciliation
comparison of a list of current medications with a previous list, which is done at every hospitalization and every clinic visit. Include OTC and herbals.
OTC
Over the Counter
Family History
Age and health or cause of death of blood relatives
Health of close family members (spouse, children)
Family history of various conditions such as heart disease, high blood pressure, stroke, diabetes, blood disorders, cancer, obesity, mental illness, and
Genogram
a graphic family tree that uses symbols to depict the gender, relationship, and age of immediate blood relatives in at least 3 generations
Purpose of Review of Systems
-evaluate the past and present health state of each body system
-double check in case any significant data were omitted in the Present Illness section
-evaluate health promotion practices
The order of review of systems
head to toe
Review of Systems
General overall health state
Skin
Hair
Head
Eyes
Ears
Nose and sinuses (drainage, bleeding?)
Mouth and throat (sores, ulcers, sore throats?)
Neck (swelling, lumps, range of motion?)
Breast (Lumps, discharge, pain?)
Axilla (Lumps, pain?)
Respiratory system
If the Present Illness section covered a body system
you do not need to repeat all the data
When recording information
avoid writing "negative" after the system heading... You need to record the "presence or absence of all symptoms" otherwise the reader does not know about which factors you asked
History should be limited to
patient statements or subjective data... factors that the person SAYS were or were not present
General Overall Health
present weight, fatigue, weakness, or malaise, fever, chills, sweats
Sexual Health
-current sexual activity
-level of sexual satisfaction
-changes in ejaculation
-contraceptives
-contact with someone who has an STD
Functional Assessment
measures a person's self-care ability in the areas of general physical health or absence of illness (ADL's)
Functional Assessment Asks
-self esteem
-activity/exercise
-sleep
-nutrition/eliminatinon
-interpersonal relationships
-spiritual resources
-Personal habits
-Tobacco
-Alcohol
-Street drugs
-Environment/hazards
-Occupational health
-Intimate partner violence
FICA
Spiritual Resources
Faith, Influence, Community and Adress
CAGE test
Uncontrolled Alcoholic
Cut down, Annoyed, Guilty and Eye-opener
Perception of Health
How do you define health?
How do you view your situation now?
What are your concerns/goals?
What do you think will happen in the future?
What do you expect from your health care providers?
The health history is
adapted to include information specific for the age and developmental stage of the child
Past Health-Developmental
-Prenatal Status
-Labor and Delivery
-Postnatal Status
-Childhood Illnesses
-Accidents (how the child was treated)
-Serious Chronic Illness
-Operations/Hospitalizations
-Immunizations
-Allergies
-Medications
Children
A baby's history starts with the mother's prenatal experience and birth experience
Consider comparing to developmental norms such as those found on the Denver Chart include nutritional assessment over a week (not just 24 hrs)
Adolescents
The HEEADSS Psychosocial Interview
p. 65
health history provides
1. a complete picture of the persons past present health
2. describes the person as whole
3. how the person interacts with the environment
4. strengths and coping skills
5. what person is doing right
6. lifestyle : exercise, diet, substance abuse, risk re
new immigrant additions
1. biographical data
2. spiritual resources
3. past health
4. health perception
5. nutritional
A patient tells the nurse, "I haven't felt well lately. I just had to come in for a check-up." Under which section of the health history will the nurse record this information?
a. Past health history
b. Present health status
c. Reason for seeking care
d.
c. Reason for seeking care
How should the nurse record a patient's reason for seeking care?
a. Use the North American Nursing Diagnosis Association (NANDA) list.
b. Write the symptoms without quotations.
c. Record the symptoms in the patient's words.
d. List all of the complaints o
c. Record the symptoms in the patient's words
What does the nurse record in the biographic information section of the health history?
a. Past illnesses
b. Usual source of health care
c. Dietary preferences
d. Family health history
b. Usual source of health care